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8. Foot and Ankle MCQs

Practice Set 49 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 961

Topic: 8. Foot and Ankle

A 55-year-old active male presents with chronic pain and stiffness in his right great toe, particularly during push-off. Physical examination reveals a dorsal exostosis and pain with passive dorsiflexion of the MTP joint, which is limited to 20 degrees. Radiographs show significant dorsal osteophyte formation, joint space narrowing, and subchondral sclerosis affecting approximately 50% of the joint surface. According to the Coughlin and Shurnas classification, what stage of hallux rigidus does this patient most likely have?

. Stage 1
. Stage 2
. Stage 3
. Stage 4
. Stage 5

Correct Answer & Explanation

. Stage 3

Explanation

Correct Answer: CThe Coughlin and Shurnas classification for hallux rigidus is widely used. Stage 1 involves mild flattening of the metatarsal head, minimal osteophytes, and good joint space. Stage 2 presents with moderate osteophytes (dorsal and dorsal-medial), mild-to-moderate joint space narrowing, and flattening of the metatarsal head, with 20-50% cartilage involvement. Stage 3 is characterized by significant osteophytes, moderate-to-severe joint space narrowing, and subchondral sclerosis/cysts, with greater than 50% cartilage involvement and pain at end-range motion. Stage 4 involves ankylosis or severe degenerative changes throughout the entire joint. This patient's presentation of significant dorsal osteophyte formation, joint space narrowing, subchondral sclerosis, and limited dorsiflexion to 20 degrees, affecting approximately 50% of the joint, aligns with Stage 3 hallux rigidus.

Question 962

Topic: 8. Foot and Ankle

Which of the following intrinsic foot muscles is primarily responsible for flexion of the great toe MTP joint and contributes significantly to the 'windlass mechanism' that is impaired in hallux rigidus?

. Abductor hallucis
. Flexor hallucis brevis
. Adductor hallucis
. Lumbricales
. Flexor digitorum brevis

Correct Answer & Explanation

. Flexor hallucis brevis

Explanation

Correct Answer: BThe flexor hallucis brevis (FHB) is an intrinsic foot muscle with two heads (medial and lateral) that insert into the base of the proximal phalanx, encasing the sesamoids. It is the primary flexor of the great toe MTP joint and plays a critical role in stabilizing the MTP joint during gait, particularly during the push-off phase by facilitating the 'windlass mechanism'. Impairment of this mechanism due to MTP joint stiffness (hallux rigidus) alters normal gait biomechanics. Abductor hallucis abducts and flexes, adductor hallucis adducts and flexes, while lumbricales and flexor digitorum brevis act on lesser toes.

Question 963

Topic: 8. Foot and Ankle

A 48-year-old patient with Stage 2 hallux rigidus (Coughlin and Shurnas) continues to experience pain despite activity modification, appropriate footwear, and NSAIDs. Dorsiflexion is limited to 30 degrees, and a prominent dorsal osteophyte is palpable. Which surgical procedure is generally considered the most appropriate initial intervention for this stage, aiming to preserve joint motion?

. MTP joint arthrodesis
. Interpositional arthroplasty
. Dorsal cheilectomy
. Proximal phalangeal osteotomy (Moberg)
. Metatarsal head resection arthroplasty

Correct Answer & Explanation

. Dorsal cheilectomy

Explanation

Correct Answer: CFor Stage 2 hallux rigidus, where there is moderate joint space narrowing and moderate osteophyte formation, but still reasonable cartilage (50-75% intact), a dorsal cheilectomy is typically the first-line joint-preserving surgical option. It involves removing the dorsal osteophytes and often a portion of the dorsal metatarsal head to decompress the joint and improve dorsiflexion. Moberg osteotomy is often performed in conjunction with a cheilectomy, or for more advanced cases, to improve dorsiflexion via a plantarflexion osteotomy of the proximal phalanx. Arthrodesis and arthroplasty are generally reserved for more advanced stages (Stage 3 and 4) or failed conservative/joint-sparing procedures. Metatarsal head resection arthroplasty (Keller arthroplasty) is largely historical due to associated complications like transfer metatarsalgia and instability.

Question 964

Topic: Forefoot

What is the primary biomechanical advantage of performing a Moberg osteotomy (dorsal closing wedge osteotomy of the proximal phalanx) in conjunction with a cheilectomy for hallux rigidus?

. To increase plantarflexion of the great toe MTP joint
. To offload the first metatarsal head
. To improve dorsiflexion of the great toe MTP joint by rotating the proximal phalanx dorsally
. To correct hallux valgus deformity
. To enhance intrinsic muscle function

Correct Answer & Explanation

. To improve dorsiflexion of the great toe MTP joint by rotating the proximal phalanx dorsally

Explanation

Correct Answer: CA Moberg osteotomy, a dorsal closing wedge osteotomy of the proximal phalanx, effectively plantarflexes the proximal phalanx relative to its articular surface. This maneuver indirectly increases functional dorsiflexion at the MTP joint by changing the resting position of the proximal phalanx, thereby reducing impingement and improving the toe-off phase of gait. It is typically performed in conjunction with a cheilectomy for Stage 2 or early Stage 3 hallux rigidus, or when isolated cheilectomy is insufficient to restore adequate dorsiflexion. It does not primarily offload the metatarsal head, correct hallux valgus (though some subtle correction might occur), or directly enhance intrinsic muscle function.

Question 965

Topic: Forefoot

A 60-year-old sedentary patient with Stage 4 hallux rigidus presents with severe, constant pain in the first MTP joint, significantly affecting daily activities. Radiographs show complete obliteration of the joint space and subchondral bone erosions. Considering the patient's age and activity level, which surgical option is generally considered the gold standard for pain relief and functional improvement in this scenario?

. Dorsal cheilectomy
. Proximal phalangeal osteotomy (Moberg)
. First MTP joint arthrodesis
. Interpositional arthroplasty
. Metatarsal shortening osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

Correct Answer: CFor Stage 4 hallux rigidus, characterized by severe degenerative changes or ankylosis, joint-preserving procedures like cheilectomy or Moberg osteotomy are inappropriate as they cannot address the diffuse damage. First MTP joint arthrodesis (fusion) is considered the gold standard for severe hallux rigidus, especially in active patients, or when other procedures have failed. It provides reliable pain relief and a stable, pain-free platform for push-off, though it sacrifices MTP joint motion. While interpositional arthroplasty or MTP joint implants might be considered for less active patients or those unwilling to sacrifice motion, arthrodesis typically offers the most predictable and durable pain relief for severe end-stage disease. A sedentary patient might be a candidate for arthroplasty, but for reliable pain relief and functional improvement, especially with complete obliteration, arthrodesis is still considered the gold standard for overall success.

Question 966

Topic: 8. Foot and Ankle

What is the most common radiographic finding in early stages of hallux rigidus?

. Complete MTP joint ankylosis
. Subchondral cysts in the metatarsal head
. Dorsal osteophyte formation on the first metatarsal head
. Significant valgus deformity of the great toe
. Bone marrow edema on MRI

Correct Answer & Explanation

. Dorsal osteophyte formation on the first metatarsal head

Explanation

Correct Answer: CIn the early stages of hallux rigidus, the most common and often first radiographic sign is the formation of a dorsal osteophyte on the first metatarsal head. This osteophyte impinges on the base of the proximal phalanx during dorsiflexion, leading to restricted motion and pain. Complete ankylosis is a late-stage finding. Subchondral cysts and significant valgus deformity are less specific or later findings. Bone marrow edema is an MRI finding, not typically a primary radiographic finding for early diagnosis.

Question 967

Topic: Forefoot

Which of the following is considered a relative contraindication to first MTP joint arthroplasty with an implant for hallux rigidus?

. Older, less active patient
. Rheumatoid arthritis
. Previous infection in the surgical field
. Failed cheilectomy
. Moderate hallux valgus deformity

Correct Answer & Explanation

. Previous infection in the surgical field

Explanation

Correct Answer: CPrevious infection in the surgical field is a strong contraindication for any joint replacement procedure, including MTP joint arthroplasty with an implant, due to the high risk of recurrent infection and subsequent implant failure. Older, less active patients are often considered good candidates for arthroplasty as motion preservation is prioritized over the robust stability of an arthrodesis. Rheumatoid arthritis can be an indication for arthroplasty, especially with polyarticular involvement. Failed cheilectomy is a common indication for salvage procedures like arthroplasty or arthrodesis. Moderate hallux valgus may need concomitant correction but isn't a direct contraindication to implant arthroplasty itself, though some implants may not be suitable.

Question 968

Topic: 8. Foot and Ankle

When performing a cheilectomy for hallux rigidus, what is the recommended amount of bone to resect from the dorsal aspect of the first metatarsal head to achieve adequate decompression and improve dorsiflexion?

. Less than 5% of the metatarsal head
. Approximately 10-15% of the dorsal articular surface
. At least 30-40% of the entire metatarsal head
. Only the visible osteophyte, no articular cartilage
. The entire dorsal third of the metatarsal head

Correct Answer & Explanation

. Approximately 10-15% of the dorsal articular surface

Explanation

Correct Answer: BWhen performing a dorsal cheilectomy, the goal is to remove the dorsal osteophytes and approximately 10-15% of the dorsal articular cartilage of the metatarsal head. This amount is generally considered sufficient to decompress the joint, improve dorsiflexion, and prevent impingement without excessively shortening the metatarsal or destabilizing the joint. Removing only the visible osteophyte might be insufficient if impingement persists. Resecting 30-40% or the entire dorsal third is excessive and can lead to instability, transfer metatarsalgia, or shortening.

Question 969

Topic: Forefoot

A 30-year-old professional athlete develops severe, painful hallux rigidus (Coughlin and Shurnas Stage 3-4). He requires a stable, pain-free foot for continued high-impact activities. Which surgical option would you most strongly recommend for this patient?

. Keller arthroplasty
. Silicone interpositional arthroplasty
. First MTP joint arthrodesis
. Dorsal cheilectomy with Moberg osteotomy
. Resection of the proximal phalanx base

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

Correct Answer: CFor a young, active professional athlete with severe hallux rigidus (Stage 3-4), a first MTP joint arthrodesis is the most appropriate and recommended option. While it sacrifices motion, it provides a highly stable, pain-free, and durable platform capable of withstanding high-impact activities required by athletes. Cheilectomy with Moberg is generally for earlier stages (Stage 2-3). Keller arthroplasty (resection of proximal phalanx base) is largely abandoned due to high rates of complications like transfer metatarsalgia and instability. Silicone implants have a high failure rate in active patients and are prone to synovitis and osteolysis. Interpositional arthroplasty may be considered for less active patients but does not provide the same level of stability and predictable outcomes for high-demand individuals.

Question 970

Topic: 8. Foot and Ankle

A 55-year-old male presents with advanced hallux rigidus (Coughlin and Shurnas Grade 4). He elects to undergo a first metatarsophalangeal (MTP) joint arthrodesis. To optimize postoperative gait and patient satisfaction, what is the ideal position for the arthrodesis?

. Neutral dorsiflexion, 0 degrees of valgus, and neutral rotation
. 10 to 15 degrees of dorsiflexion relative to the floor, 10 to 15 degrees of valgus, and neutral rotation
. 25 degrees of dorsiflexion relative to the floor, 5 degrees of varus, and 10 degrees of pronation
. 5 degrees of plantarflexion, 15 degrees of valgus, and 5 degrees of supination
. 20 to 25 degrees of dorsiflexion relative to the first metatarsal, 0 degrees of valgus, and 10 degrees of supination

Correct Answer & Explanation

. 10 to 15 degrees of dorsiflexion relative to the floor, 10 to 15 degrees of valgus, and neutral rotation

Explanation

The ideal position for 1st MTP arthrodesis is 10-15 degrees of dorsiflexion relative to the floor, 10-15 degrees of valgus, and neutral rotation. Excessive dorsiflexion causes IP joint arthritis, while inadequate dorsiflexion leads to altered gait and vaulting.

Question 971

Topic: 8. Foot and Ankle

A 45-year-old runner presents with pain and stiffness in the right great toe. Radiographs demonstrate dorsal osteophytes and mild joint space narrowing, consistent with Coughlin and Shurnas Grade 2 hallux rigidus. Which of the following conservative management strategies is most appropriate?

. Flexible minimalist footwear to promote natural foot biomechanics
. A stiff-soled shoe with a Morton's extension and rocker bottom
. A medial longitudinal arch support with a metatarsal pad
. A solid ankle-foot orthosis (AFO)
. Corticosteroid injection into the first tarsometatarsal (TMT) joint

Correct Answer & Explanation

. A stiff-soled shoe with a Morton's extension and rocker bottom

Explanation

Conservative management of early to moderate hallux rigidus focuses on limiting first MTP joint motion. A stiff-soled shoe with a rocker bottom and a rigid Morton's extension effectively reduces dorsiflexion during the terminal stance phase of gait.

Question 972

Topic: 8. Foot and Ankle

A patient with Coughlin and Shurnas Grade 1 hallux rigidus is scheduled for a cheilectomy. To optimize postoperative dorsiflexion while preventing joint instability, what is the maximum recommended amount of the dorsal metatarsal head that should be resected?

. 10%
. 30%
. 50%
. 70%
. 100%

Correct Answer & Explanation

. 30%

Explanation

During a cheilectomy, approximately 20% to 30% of the dorsal aspect of the first metatarsal head should be resected along with dorsal osteophytes. Resecting more than 30% to 40% risks compromising the articulation and destabilizing the joint.

Question 973

Topic: 8. Foot and Ankle

A 45-year-old active male presents with dorsal midfoot pain and limited hallux dorsiflexion. Radiographs show a preserved first MTP joint space with a large dorsal osteophyte (Coughlin and Shurnas Grade 2). He fails nonoperative management. If a cheilectomy is performed, what is the recommended extent of dorsal metatarsal head resection?

. 10-15%
. 25-30%
. 45-50%
. 60-70%
. Excision of the entire dorsal half of the metatarsal head

Correct Answer & Explanation

. 25-30%

Explanation

During a cheilectomy for hallux rigidus, approximately 25-30% (up to one-third) of the dorsal metatarsal head should be resected. Resecting more than this can compromise the joint articulation and destabilize the MTP joint.

Question 974

Topic: Forefoot

A 65-year-old woman undergoes a first MTP arthrodesis for end-stage hallux rigidus. To optimize normal gait kinematics and prevent transfer metatarsalgia, what is the ideal position for fusion of the first MTP joint?

. Neutral dorsiflexion and neutral valgus
. 10-15 degrees of dorsiflexion and 10-15 degrees of valgus
. 25-30 degrees of dorsiflexion and neutral valgus
. 5-10 degrees of plantarflexion and 15 degrees of valgus
. 10-15 degrees of dorsiflexion and 25-30 degrees of valgus

Correct Answer & Explanation

. 10-15 degrees of dorsiflexion and 10-15 degrees of valgus

Explanation

The ideal position for first MTP arthrodesis is 10 to 15 degrees of valgus and 10 to 15 degrees of dorsiflexion relative to the floor. This allows for normal toe-off during gait and accommodates most footwear.

Question 975

Topic: 8. Foot and Ankle

A 55-year-old runner presents with severe first MTP joint pain. Radiographs reveal less than 25% joint space remaining, severe flattening of the metatarsal head, and multiple large osteophytes. Examination reveals pain at both extremes of motion. Which of the following is the most reliable surgical treatment?

. Cheilectomy alone
. First MTP arthrodesis
. Keller resection arthroplasty
. Moberg osteotomy
. First MTP joint silicone arthroplasty

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4) with pain throughout the arc of motion and severe joint space narrowing, first MTP arthrodesis is the gold standard and most reliable procedure for pain relief and functional restoration.

Question 976

Topic: Forefoot

In the surgical management of hallux rigidus, a Moberg osteotomy (a dorsal closing wedge osteotomy of the proximal phalanx) is most appropriately utilized as an adjunct procedure to achieve which of the following goals?

. Increase true first MTP joint plantarflexion
. Increase total first MTP joint range of motion
. Correct metatarsus primus varus
. Improve apparent hallux dorsiflexion to facilitate toe-off during gait
. Decompress the sesamoid complex

Correct Answer & Explanation

. Improve apparent hallux dorsiflexion to facilitate toe-off during gait

Explanation

A Moberg osteotomy does not increase the true range of motion of the first MTP joint. Instead, it shifts the existing arc of motion into more dorsiflexion, improving apparent dorsiflexion and reducing impingement during the toe-off phase of gait.

Question 977

Topic: 8. Foot and Ankle

Which of the following shoe modifications is considered the most appropriate first-line conservative management for symptomatic hallux rigidus?

. Flexible sole shoe with a metatarsal pad
. Rocker-bottom sole with a Morton extension
. Medial longitudinal arch support with a heel lift
. Lateral heel wedge with a deep toe box
. Minimalist footwear to increase toe flexion

Correct Answer & Explanation

. Rocker-bottom sole with a Morton extension

Explanation

A rigid Morton extension prevents painful dorsiflexion of the first MTP joint, while a rocker-bottom sole compensates for the lost motion by facilitating a smooth roll-through during the toe-off phase of gait.

Question 978

Topic: Forefoot

A 50-year-old male undergoes a dorsal cheilectomy for Grade 2 hallux rigidus. Postoperatively, he complains of persistent numbness along the dorsomedial aspect of the great toe. Which nerve was most likely injured during the surgical approach?

. Deep peroneal nerve
. Medial dorsal cutaneous nerve
. Sural nerve
. Lateral plantar nerve
. Saphenous nerve

Correct Answer & Explanation

. Medial dorsal cutaneous nerve

Explanation

The medial dorsal cutaneous nerve, a branch of the superficial peroneal nerve, supplies sensation to the dorsomedial aspect of the hallux. It is highly susceptible to injury during the standard dorsal or dorsomedial surgical approach to the first MTP joint.

Question 979

Topic: 8. Foot and Ankle

A 70-year-old patient with severe hallux rigidus underwent a silastic interposition arthroplasty of the first MTP joint 7 years ago. She now presents with progressive midfoot pain and swelling. Radiographs show significant osteolysis and cystic changes around the first metatarsal head and proximal phalanx. What is the most likely diagnosis?

. Septic arthritis
. Gouty arthropathy
. Silicone synovitis (foreign body reaction)
. Charcot arthropathy
. Stress fracture of the adjacent second metatarsal

Correct Answer & Explanation

. Silicone synovitis (foreign body reaction)

Explanation

Silicone synovitis is a well-documented long-term complication of silastic implants in the first MTP joint. It results from a foreign-body macrophage response to silicone wear debris, leading to progressive osteolysis and cystic bone changes.

Question 980

Topic: 8. Foot and Ankle

Metatarsus primus elevatus has been debated as a potential predisposing factor for the development of hallux rigidus. Which radiographic finding best defines metatarsus primus elevatus?

. Dorsal elevation of the first metatarsal relative to the second metatarsal on a weight-bearing lateral radiograph
. Plantarflexion of the first metatarsal relative to the talonavicular joint
. Increased intermetatarsal angle between the first and second rays
. Dorsal subluxation of the proximal phalanx on the metatarsal head
. Presence of a dorsal bunion with apex plantar angulation of the first metatarsal

Correct Answer & Explanation

. Dorsal elevation of the first metatarsal relative to the second metatarsal on a weight-bearing lateral radiograph

Explanation

Metatarsus primus elevatus is defined radiographically by the dorsal elevation of the first metatarsal shaft relative to the second metatarsal shaft on a weight-bearing lateral foot radiograph. This theoretically limits the functional dorsiflexion of the first MTP joint.

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